The topic of youth substance abuse has both an intellectual and academic aspect to it, as well as a very personal and emotional aspect. One can talk about demographics of substance abuse, the effects of psychoactive substances on the brain, procedures for prevention and treatment, and other important topics. But the fact is that substance abuse often has profound effects on the personal lives of friends, family, the community as a whole, and abusers themselves. This chapter provides individuals with an opportunity to write about both aspects of the youth substance abuse issue.
We were all doing homework on the floor when Ian got a call from work. We had to finish a group paper on the Steller sea lion but spent most of the night laughing over our attempts to remember its scientific name. Cats climbed over laptops and snow boots. Nintendo 64 was waiting when we were finished. I had only been close with this group of friends for a while, but already they had taught me much about being a compassionate member of our college community.
Ian came back from the bedroom, phone in hand. Someone had to cover our friend Alex’s shift at the hotel tonight, he said. But he had to repeat himself before we understood—Alex wasn’t going to be there because he was dead.
The feeling fell over us slowly. Shock blinded sadness, but horror was immediate. He was alone. He overdosed. He’s gone. We each tried to remember the last time we heard Alex laugh, then realized we never would again.
I think we got the email from the university before Ian left for work. The president and his wife sent their thoughts and prayers with the curt news of Alex’s death. It was the same template email they sent out a few weeks before, when another student died after an accidental house fire. Counselors would be available. Class would continue as scheduled.
At the University of North Dakota in Grand Forks (UND), there are few young people who don’t know someone whose life has been impacted—or ended—by drug use. I went through high school in town and joined the ranks of those afflicted just a month after graduation, when Christian, the friendly football player I sat next to in English class, was found dead in the grass outside his parents’ home.
The same week, 17-year-old Elijah overdosed in a similar way. He and his brother Justin ate chocolate they were told was cooked with psilocybin—the ingredient in psychedelic mushrooms. But Justin later told police that when the effects began to kick in, he knew it was something else. By the time the ambulance arrived, he knew, too, that his brother was gone.
Autopsies later found that substances called NBOMe and powdered fentanyl were to blame for many of the recent overdose deaths in town. These substances are cheaper to produce than hallucinogens like LSD, but since their effects are somewhat similar, dealers often sell these extremely potent drugs as something safer and more marketable than what they really are. Often, dealers themselves don’t even know what they’re pushing.
When I returned home from my friends’ house, our sea lion paper was nowhere near finished. Somewhere far away, Alex’s family grieved. On campus, police scrambled to figure out how to keep us safe.
That night in bed, I didn’t know what to dream, and I didn’t dream at all. But in the morning I found a new email from university police, this time encouraging students to turn in their roommates for “unusual behavior” and to “keep (their) eyes open for such things as small pieces of tin foil (and) baggies.” “(Due) to the nature of the way (designer drugs) are being obtained,” campus police explained, “users cannot be certain of what substance(s) they are actually ingesting.”
On this, the university is right. Many of the substances that have killed my classmates were bought online, by other young people who are now in prison for it. They didn’t know what they had or how to use it safely—this is why overdose happens. But the university’s emphasis on promoting fear and its recent investment in a police drug dog send conflicting messages. Are all welcome in Grand Forks? Or are a few personal decisions assumed to invalidate a student’s right to sincere protection?
Three months after Alex died, so did my friend Evan. He, too, was alone. He, too, overdosed. He, too, is gone forever. Wondering after the fact if he should have been arrested does nothing to bring him back.
It was dark inside the tent. Music and voices swirled outside, rolling down the hill toward the stage. Three of us huddled over a clean zip-seal bag in the lamplight. That’s when a young man I’ll call Roger showed me something I’d never known about. “I think I have some high quality MDMA,” he said. “But we’re going to test it to see if it’s MDMA at all.”
Zip. Click. Snap. He tapped the side of the bag with his thumb, gently holding a plastic test tube in his other hand. A tiny amount of white powder trickled to the bottom of the clear container. Closing the bag, he produced a small vial of yellow liquid.
Pop. Drip. Drip. Two drops slid along the inside of the tube. When it made contact with the powder, it bubbled, fizzed, and began to change color. He snapped the lid closed and flicked the side of the tube. When the reaction ended, I held the light closer.
Black.
“What does that mean?” I asked.
Roger grabbed the Bunk Police substance testing kit someone brought to the music festival I found myself at. Flipping it over, he studied the colorful diagram inside. “It’s MDMA,” he exclaimed. “I almost don’t believe it.”
Months later, I learned why he was so surprised. Far from the muffled excitement of that dim tent, at the University of Colorado Boulder, I met James. At the age of 19, James had gone to war as an army combat medic. Returning home with post-traumatic stress disorder, he sought every kind of treatment imaginable. Nothing helped. When it seemed all hope was gone, he found a military-sponsored treatment utilizing the psychoactive properties of the illegal party drug MDMA (or “Molly”, “Ecstasy”) to treat PTSD. “MDMA therapy helped give me my life back,” James told me. “And now I want to give my life to spreading perspective on drugs.”
That perspective is changing worldwide, and the new name of the drug use safety game is “harm reduction.” But the concept goes far beyond making medicines available to those in need. It’s about reducing the amount of dangerous situations that substance users, community members, and police officers are exposed to on a daily basis. It includes enforcement and detection but emphasizes education—not just of the health risks of using mind-altering substances, but of practical, empowering actions that directly reduce overdose and arrest rates.
Enter, the Psychedelic Club—a student organization James founded with a handful of friends at CU Boulder. At first, the group consisted of five like-minded classmates chatting beneath a tree in the campus garden. Today, more than 45 students attend their meetings every week—and that’s just in Boulder. Chapters have been founded at four other universities, and with official support from MAPS—the world’s largest scientific organization dedicated to researching psychedelic substances—the club is just beginning to have a serious impact on reducing harm at schools across the country.
Just one of the services they provide is easy access to free substance testing. Bring a $20 bill to a Psychedelic Club meeting, and leave with a Bunk Police test kit. Bring it back the next day, and your $20 is returned. Of those who used the Club’s kits to test what they thought was MDMA last year, over 88 percent actually had meth.
That statistic is so horrifying, I must write it again—nearly 9 out of 10 students at CU Boulder bought methamphetamine from dealers who said they were selling them Molly. Others found bath salts in their Ecstasy. Another 40 percent of LSD tested with the Club’s kits were actually research chemicals like NBOMe—the same stuff that’s killing my classmates in North Dakota.
None can say if the testing prevented the university from having to send more death notice emails. But if someone you knew decided to try a powder, would you want them to know what’s in it?
When I returned to North Dakota, my good friend Larry and I wrote an article in our student newspaper. We talked about substance testing. We explained the fatal weaknesses of our university’s “abstinence-only” attitude. We expressed our love for those who are gone. Like many articles we’ve written in the student paper, it seemed to have no impact. Those who didn’t know the kids who died still saw no problem. Those who did still saw no solution.
Then I met Cara. She’s the one at UND responsible for calling the parents of students who die on campus, and she’s done it way more than she wishes she’s had to. As we agree, one call is too many.
I was in her office with a fellow student for an unrelated reason, when she caught me on the way out her door. “Do you have an extra minute?” I remember she asked me. “I’d like to know more about these substance testing kits you wrote about in the paper.”
In my whole life growing up in Grand Forks, I would never have imagined that an adult like Cara in a position of influence would ever want to start a conversation with a student about substance use that didn’t start and end with “just say no.” To say the least I was surprised. As we continued talking, I realized the depth of her sincerity. “All are welcome,” she told me. “That’s the message we need to get across.”
It was then Larry had an idea that would end up consuming a large part of our emotional lives. He emailed Frank—the coolest professor at UND (at least the only one I know with a bobblehead made in his image). Frank teaches “Drugs & Society” and dedicates himself to traveling up and down the Red River Valley talking to folks about harm reduction. To this day, I have met no other teacher with a more blatant selflessness than Frank.
We met in the student newspaper office. I told him about James and the Psychedelic Club, about their success uniting the student body with the administration and campus police. He felt the same and showed us how we might empower ourselves and rally our classmates. He spoke of other students, years ago, excited about the same idea of reducing harm at UND. But like those before them, they graduated, and their ideas disappeared with them into “the real world.”
Not this time.
My friends and I guest-lectured in Frank’s class a few weeks ago before winter break. We spoke for an hour and a half about those who are gone and what we can do to protect all those who remain. Immediately, we felt the impact of Frank’s creation; more than a dozen of his students spoke to us after class about forming a chapter of the Psychedelic Club at UND. We have our first meeting in a couple weeks.
But we can’t do it alone. Thankfully, we aren’t. Our university is now open, unlike most, to being sincerely responsive to its student community’s right to harm reduction. Cara has facilitated candid student discussions with administrators. Frank has given us the gift of self-inspiration. James drafted our new chapter’s bylaws.
Meanwhile, Alex is gone. Christian is gone. Elijah is gone. Evan is gone. And so many others.
The moment after we students met with Cara together for the first time, I stepped out into the nighttime rain, thoughts swirling in my head rolling down the slippery street. I walked for 30 minutes along the length of University Avenue on my way home coming in from the cold. In this short time, I passed three different cars pulled over by police on campus. I didn’t know if everybody in trouble deserved to be there. I didn’t know how every officer were treating their fellow citizens. It felt, in fact, like I knew nothing at all.
As I passed the religious center, I stopped dead in the grass. White banners streamed in the evening breeze. Red, white, and blue police lights flashed across them with a frenzied energy. I’d seen these signs before but never paid enough attention to them.
“ALL ARE WELCOME,” read one.
“CHANGE,” read another.
That night in bed, I did know what to dream, and decided to dream all I could before it were all gone.
I’m Billy Beaton, a wildlife biology major at the University of North Dakota. The overwhelming passion of my friends and classmates has helped us create change in our community, and with the support of our instructors we will continue to empower those around us to communicate that which matters to us all. Our website, SandbaggerNews.com, will become live later this year.
Why is it that kids get interested in alcohol relatively early in life? Is the attraction to alcohol some sort of fate residing in the stars, or is there an often-ignored intrinsic biological connection? Perhaps something primordial or prehistoric that left behind clues in the earliest days of human civilization. The ancients would no doubt have first looked to the heavens for answers.
As the new year dawned in 2015, Comet Lovejoy blazed brightly across the sky. Surprisingly, for a comet, it contained water and 5 percent ethanol (ethyl alcohol), the same intoxicating alcohol found in beer, wine, and hard beverages. Though the comet failed the breathalyzer test, this did not mean alien life forms drunkenly driving among the stars and planets. Ethanol forms naturally via pure physical chemistry in outer space. Indeed, an ethanol-laden molecular cloud called Sagittarius B2 lies in the center of our galaxy. Astrophysicists calculated that a distillery in Sagittarius B2 to separate out and condense ethanol would yield over an octillion (a 1 followed by 28 zeros) fifths of 200 proof alcohol; more than humans have fermented in Earth’s history (Biver 2015; Zuckerman et al. 1975).
There is no way of completely avoiding ethanol. Rotting fruit ferments and produces ethanol, which may be how our ancestors first developed a taste for alcohol. Animals attracted to fermenting fruit further plant reproduction by spreading seeds. Green plants ferment ethanol inside leaves and roots. Pine, spruce, dogwood, and magnolia trees emit ethanol into the atmosphere when “stressed” (e.g., by drought or flooding), dying, or decaying. Pine beetles and ambrosia beetles attracted to ethanol hone in on weakened trees for the final kill. In other words, ethanol links plant and animal life.
Strangely, yeast and fungal microbes fermenting fruit and grain starch sugars into beer and wine are usually killed before ethanol concentrations reach 15 percent. This may make fermentation microbes the ultimate self-abusers, as they keep at it until poisoning themselves to death. It also makes high proof ethanol a good medical antiseptic or sanitizing weapon against microbes.
Other microbes transform ethanol into vinegar or acetic acid, useful for pickling; and also a controlled spoilage or food preservation process. “Fermentation was not invented, but rather discovered,” writes the University of Georgia’s Brian Nummer (Nummer 2002). “It not only could preserve foods, but it also created more nutritious foods and was used to create more palatable foods from less than desirable ingredients.” For example, rotting bread grain was likely shunted into ancient beer breweries.
“Given the ancient and cosmopolitan reliance on fermented foods and the cultural inheritance of their use, I suggest that humans … first encountered high concentrations of ethanol through fermentation processes that were initially fostered for the purpose of food preservation,” writes Douglas J. Levey (Levey 2004). “As they discovered the inebriating qualities of some fermented foods, they focused attention on those fermentative processes, ultimately leading to the beer and wine industries of today…. Addiction to ethanol may be analogous to addiction to caffeine, nicotine, heroin, or cocaine. All are secondary metabolites that humans have learned to concentrate and that provide a desired physiological response.”
Distillation concentrates ethanol, making possible high proof spirits and faster ingestion of higher doses. Medieval monks in monasteries pioneered simple distillations to remove water from wines; boosting ethanol content for brandies, fruit liquors, and medicinal wines. The monks learned distillation techniques from alchemists, secretive “philosopher-chemists” who viewed distillation as a mystical, almost religious quest to obtain the pure spirit or essence of a substance.
Medieval wine distillates, called aqua vitae (“water of life”) or the fifth essence (after earth, air, fire, and water), were more like prescription remedies, often fermented with herbs, like ancient Greek medicinal wines. Aqua vitae was not intended for social drinking, and mood elevation was considered a medicinal benefit. Monasteries of the period were healing centers with medicinal herb gardens, and providers of medical treatment for the poor, along with food, clothing, and other charity.
The Industrial Revolution marked the onset of mass production and consumption of high proof spirits. Political upheaval and revolutions put an end to monastery infirmaries dispensing aqua vitae. Medieval alchemy morphed into modern chemistry. The new idea was multiple or continuous distillation cycles to obtain higher concentrations of ethanol, which was deemed the true essence or spirit of the beverage.
An English naval blockade of imports into France was a catalyst. “Napoleon offered a prize for sugar beet production and fermentation to gain independence from British imports of sugar and alcohol,” wrote Professor Norbert Kockmann (Kockmann 2014). “A series of patents on distillation equipment was issued from 1801 to 1818,” including “the continuously working distillation patented by Jean-Baptiste Cellier-Blumenthal in 1813.” This turned grape wine into purified ethanol, an exceptional solvent for extracting beet sugar as white as pure cane sugar. Plus distillation was economical, as ethanol was purified multiple times and reused. New and improved distillation columns soon enabled new industries and mass production of myriad high proof spirits. By 1873, Germany alone had over 16,000 working distilleries, including one producing a 60–80 percent alcohol potato brandy.
We lack statistics for comparing alcohol abuse by age group in different eras. Suffice it to say, the ancient Greek word “symposium” originally referred to drinking parties featuring intellectual discussions. The ancient world had myriad drinking, cooking, and medicinal wines fermented with Mediterranean herbs. Dioscorides, a founder of modern pharmacy, detailed the subject in his five-volume De materia medica.
“Dioscorides described alcoholism” in the first century CE, and cautioned that “one should not drink to the point of inebriation because all drunkenness was harmful, most especially that which was continuous,” said medical historian John M. Riddle (Riddle 1985). “There is an exception to the rule about drunkenness: to be moderately drunk for several days can, in some circumstances, actually be helpful because it improves the inner state of the person, purges vapors that annoy the senses, and opens up the pores. If one resorts to this therapy, Dioscorides cautioned, one should drink much water while drinking alcohol and continue to take in water while detoxifying.” Clearly, ethanol abuse was a feature of ancient Greek and Roman life.
There is no escape from ethanol, not even in outer space. Human wisdom and détente with the ethanol molecule is the only option.
Biver, Nicolas, et al. 2015. “Ethyl Alcohol and Sugar in Comet C/2014 Q2 (Lovejoy).” Science Advances. 1(9): e1500863.
Kockmann, Norbert. 2014. “200 Years in Innovation of Continuous Distillation.” ChemBioEng Reviews. 1(1): 40–49.
Levey, Douglas J. 2004. “The Evolutionary Ecology of Ethanol Production and Alcoholism.” Integrative and Comparative Biology. 44(4): 284–289.
Nummer, Brian A. 2002. “Historical Origins of Food Preservation.” National Center for Home Food Preservation. http://nchfp.uga.edu/publications/nchfp/factsheets/food_pres_hist.html
Riddle, John M. 1985. Dioscorides on Pharmacy and Medicine. Austin: University of Texas Press.
Zuckerman, B., et al. 1975. “Detection of Interstellar Trans-Ethyl Alcohol.” The Astrophysical Journal. 196: L99–L102.
Joel Grossman is a freelance writer and book editor. Read his Biocontrol Beat blog on WordPress.com.
Electronic cigarettes have gained popularity more rapidly than almost any other contemporary consumer product on the market. The rise in this popularity has been attributed in large part to the claim that e-cigarettes might be able to help one quit smoking while providing a healthier alternative to the traditional form of smoking tobacco.
However, as such a new product on the market, no one can really be sure what the long-term effects of the electronic versions will be. That is the reason that several researchers across the world are working hard to clear up the mystery surrounding the health effects of inhaling e-cigarette vapor.
Researchers in England have been at the forefront of e-cigarette studies that are often considered a benchmark for the industry. Public Health England published an expert independent evidence review in 2015 that purported to show that e-cigarettes are as much as 95 percent less harmful than their combustible predecessors (McNeill 2015).
This was not the first time that researchers made claims of this nature. In fact, research has been piling up that e-cigarette vapor is much less harmful than cigarette smoke, a result that is coming from a variety of sources. Other prominent e-cigarette researchers, such as Robert West and Jamie Brown, outlined the potential benefits of e-cigarettes, stating that e-cigarette vapor contained far less toxins, in fact only about 1/20th that one would find in regular cigarettes (Brown and West 2014).
A 2015 study also made similar comparisons, examining how e-cigarette vapor compared not just with smoke, but also with ambient, indoor air, exhaled tobacco smoke, and regular exhaled breath. The researchers accomplished the comparison by measuring the levels of 156 different volatile organic compounds (VOCs). The researchers tested two e-cigarettes and found 25 VOCs in the vapor of one model and 17 VOCs in the other. Compared to all other kinds of air measured, e-cigarette vapor contained less of these potentially volatile compounds. Normal exhaled breath tested for 36 VOCs, while indoor air tested at 42 VOCs (Marco et al. 2015).
While it seems surprising that e-cigarette vapor contains less VOCs than the regular air one breathes, what is not a shock is how much safer they appear than regular cigarettes, where the smoke measures an astounding 86 VOCs. While not all VOCs are toxic, measuring their levels helps paints a clear picture that e-cigarette emissions really could be much safer than regular tobacco smoke.
A 2014 study also attempted to shed light on the nature of e-cigarette vapor by measuring harmful and potentially harmful constituents, otherwise referred to as HPHCs. They weighed the content of eight HPHCs, to determine the quantity in e-cigarette vapor, as well as ambient air and cigarette smoke.
The weight of the combined HPHCs in the sample size of e-cigarette vapor was recorded at less than 0.17 milligrams. The same researchers also determined that ambient air, which one breathes every day, has a comparable 0.16 milligrams of HPHCs. Again, cigarette smoke produced a staggering amount of HPHCs that measure at an average of 30.6 milligrams of HPHCs. The researchers even state that cigarette smoke “delivered approximately 1500 times more harmful and potentially harmful constituents tested” than the emissions from an e-cigarette aerosol or to the standing air in the room (Tayarah et al. 2014).
Even though the majority of the research appears to be leaning in the direction of e-cigarettes being a safer alternative to smoking, the truth is there is still so much to learn about e-cigarette vapor and, most importantly, its long-term effects.
While e-cigarette vapor does seem to be less harmful than cigarette smoke, there is still question if there is some genuine potential for e-cigarettes to do a certain kind of harm of their own. Since e-cigarettes only first hit the market back in 2007 and 2008, there simply is not the kind of evidence available to support any claims that e-cigarettes could be good, or bad for users in the long-term sense. In addition, many who start using e-cigarettes either discontinue or greatly reduce their nicotine intake along the way, making it even more difficult to gauge long-term effects.
Another area of concern is the addictive nature of nicotine in general. Most e-cigarettes, although not all, do contain some amount of nicotine. Nicotine’s addictive qualities make any item that contains nicotine, even those designed for smoking cessation purposes, a potential hazard for users who have struggled with a nicotine addiction. E-liquids used in e-cigarette devices, however, do come in varying nicotine strengths, giving the user the ability to taper off their intake and hopefully curb their addiction altogether.
Everyone wants an easy solution to the cigarette problem, but that simply does not exist. What we can hope is that all the evidence we are receiving is an indicator of the real long-term effect, if there is any at all, from using electronic cigarettes. What we are seeing now, in these studies and many others, is a promising glimpse—that perhaps these e-cigarette devices can provide users with an experience that is close enough to smoking, yet one that is far less dangerous, both to themselves and to others.
Brown, R., and J. West. 2014. “E-Cigarettes: Facts and Faction.” British Journal of General Practice. http://bjgp.org/content/64/626/442.full. Accessed on January 26, 2016.
Marco, E., et al. 2015. “A Rapid Method for the Chromatographic Analysis of Volatile Organic Compounds in Exhaled Breath of Tobacco Cigarette and Electronic Cigarette Smokers.” Journal of Chromatography A. http://www.sciencedirect.com/science/article/pii/S0021967315010821. Accessed on January 25, 2016.
McNeill, A., et al. 2015. “E-cigarettes: An Evidence Update —A Report Commissioned by Public Health England.” Public Health England. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/457102/Ecigarettes_an_evidence_update_A_report_commissioned_by_Public_Health_England_FINAL.pdf. Accessed on January 26, 2016.
Tayarah, R., et al. 2014. “Comparison of Select Analytes in Aerosol from E-cigarettes with Smoke from Conventional Cigarettes and with Ambient Air.” Regulatory Toxicology and Pharmacology. http://www.sciencedirect.com/science/article/pii/S0273230014002505. Accessed on January 25, 2016.
Amber Henning is a freelance writer and editor who is passionate about reporting and researching the truth behind the topics she covers. She holds a bachelor’s degree in English and has extensive experience covering the scientific and consumer research behind e-cigarettes, as well as several other health and wellness topics.
Neurofeedback is a neurophysiological clinical intervention that has been used as an alternative technique in the treatment of substance use disorders (SUD), primarily with adults. Although its implications for adolescents are promising, they have not yet been well established or validated. It is an intriguing treatment that has been used for many decades in an effort to regulate the brain in the areas of sleep, emotions, thinking, behaviors, and much more. When an individual is “over-regulated,” his or her brain begins to function at a faster pace, creating less impulse control and thus resulting in the inability to modulate emotions, which further intensifies poor decision making. When conducting neurofeedback, also known as brainwave biofeedback or EEG (electroencephalograph) biofeedback, electrodes are placed on the scalp at specific sites identified by the technician using the 10–20 system of placement. The placement of electrodes known as the 10–20 International System of Electrode Placement refers to five key regions of the brain: Frontal (F), Central (C), Temporal (T), Parietal (P), and Occipital (O). Odd numbers refer to the left hemispheric sites and even numbers to right hemispheric sites. The term “10–20” refers to the placement of electrodes placed 10 percent or 20 percent of the total distance between brain sites. Brainwaves are then displayed on a computer monitor with the goal being the manipulation of the patient’s brainwaves through the use of audio-visual feedback, thus informing patients of their success in making changes in brainwaves which results in changes in their physiological system as well.
The goal of neurofeedback is regulation of brainwaves using the slow-wave frequency of alpha-theta training, with either eyes open or eyes closed methods. The alpha wave (8–13 Hz) is indicative of focused relaxation and attentiveness to particular stimuli or visualizations without drowsiness. The theta wave (4–8 Hz) is even slower and is typically seen as a precursor to sleep, but the challenge is to remain deeply relaxed without lapsing into sleep. The goal of beta training is to focus on “down-training” this high-wave frequency and reduce overstimulation, anxiety, and hyperarousal and encourage an attentive, alert awareness that enhances concentration, attention, motivation, and task completion. Delta training (2–4 Hz) can also be practiced when the goal is the deactivation of high brain-wave activity or overstimulation and focuses instead on the approach to deeper levels of relaxation leading to a restful and restorative level of sleep. Sensory Motor Rhythm (SMR) training (12–15 Hz) is utilized when more specialized training is the goal which can lead to higher levels of attention and concentration, can reduce impulsivity, and can increase performance and productivity.
In a 2007 study, the principal investigator William C. Scott reported that “across the country, drug rehab programs have generally achieved a success rate of 20 to 30 percent in relapse prevention one to two years following treatment. In [his] current study, in excess of 50% of experimental subjects remained drug-free a year later.” His study involved the use of neurofeedback to teach subjects to control their brainwaves. Scott further stated, “Beyond the scientific implications of this study, which are exciting, the real significance is the hope it offers addicts, their families and our communities. For those who have tried and failed, here is a result that says, ‘try again, there are new possibilities.’ For families and communities, it’s another opportunity to free ourselves from the specter of drugs.” In the same study David A. Kaiser, PhD, experimental psychologist who designed the study, noted that “this work complements earlier findings on the efficiency of Neurofeedback in aiding recovery among severe alcoholics, but the present study extends it to opiate abusers, multiple-drug abusers, and users of stimulant-type medications such as methamphetamine and cocaine” (Kaiser and Scott 2007). Further studies have explored the use of neurofeedback for opiate addiction and reported, “Results of this study suggest neurofeedback training may produce additional benefits for increasing mental health in patients addicted to opiates, as well as being feasibly integrated with other methods” (Dehghani-Arani, Rostami, and Nadali 2013). David L. Troudeau noted in Emerging Brain-Based Interventions for Children and Adolescents that “neurofeedback is promising as a treatment modality for adolescents, especially those with stimulant abuse and attention and conduct problems. It is attractive as a medication-free, neurophysiologic, and self-actualizing treatment for substance-based, brain-impaired and self-defeating disorder” (Hirshberg, Chiu, and Frazier 2005).
There have been two protocols developed in treating SUD with neurofeedback, the initial being the Peniston Protocol. This is a multimodal intervention integrating alpha-theta neurofeedback, thermal biofeedback, diaphragmatic breathing, autogenic training, emotional catharsis, and guided imagery and visualization. This approach employed independent auditory feedback of two slow brain wave frequencies, alpha (8–13 Hz) and theta (4–8 Hz) in an eyes-closed condition to produce a hypnagogic state. Prior to neurofeedback, the patient was taught to use visualizations that included success imagery (being sober, refusing offers of alcohol, living confidently, and being happy) as they drifted down into an alpha-theta state. Repeated sessions reportedly result in longer-term abstinence and changes in personality testing. An additional approach modified from the Peniston Protocol (Scott-Kaiser modification of the Peniston Protocol) takes into consideration the inability of patients to tolerate over-stimulation too early in the withdrawal process, and has been specifically researched with cannabis and stimulant dependence populations. This protocol involves the use of attention-deficit EEG biofeedback protocols followed by the Peniston Protocol, with substantial improvement in program retention and long-term abstinence rates (Sokhadze, Cannon, and Troudeau 2008).
Research has also elucidated phenotypes in the treatment of addiction. Jay Gunkelman and Curtis Cripe evaluated this distinction and emphasized the identification of “phenotypes” in the treatment of addiction and stated, “The diagnosis of addiction is behavior based, yet current research shows that addictions have a biological base and that this basis has a genetic component.” In conclusion the authors stated, “This study is intended to add to the biopsychosocial model the understanding that pheno-type based neurofeedback, done in combination with targeted brain recovery exercises, forms the basis for a tool to assist addiction-related recovery” (Gunkelman and Cripe 2008).
A study conducted by Scott, Kaiser, Othmer and Sideroff in 2005 revealed the following, “The present study employed a Beta-SMR protocol to the alpha-theta protocol previously used in addiction studies. Beta-SMR training previously had been shown to be effective in remediating attentional and cognitive deficits…. Testing following the Beta-SMR protocol showed that this procedure improved these test measures for experimental subjects, particularly impulsivity and variability. This result may partly account for the improved treatment retention of this group” (Scott, Kaiser, Othmer and Sideroff 2005).
In conclusion, neurofeedback is an innovative and exciting treatment that is intended to complement other forms of treatment in the SUD population, including medication management, counseling and psychotherapy, 12-step programs, and meditation and relaxation techniques and should be a consideration to enhance long-term successful treatment outcomes for adolescents.
Dehghani-Arani, F., R. Rostami, and H. Nadali. 2013. “Neurofeedback Training for Opiate Addiction: Improvement of Mental Health and Craving.” Applied Psychophysiology and Biofeedback. 38 (2): 133–141.
Gunkelman, J. and C. Cripe. 2008. “Clinical Outcomes in Addiction: A Neurofeedback Case Series.” Biofeedback. 36(4). 152–156.
Hirshberg, L. M., S. Chiu, and J. Frazier. 2005. “Emerging Brain-Based Interventions for Children and Adolescents: Overview and Clinical Perspective.” Child and Adolescent Psychiatric Clinics of North America. January 14. 1–19.
Kaiser, D. A., and W. Scott. 2007. “Effect of EEG Biofeedback on Chemical Dependency.” www.EEG Info.com. Accessed on January 21, 2016.
Scott, W. C., et al. 2005. “Effects of an EEG Biofeedback Protocol on a Mixed Substance Abusing Population.” American Journal of Drug Alcohol Abuse. 31(3). 455–469.
Sokhadze, Tato M., R. L. Cannon, and D. L. Troudeau. 2008. “EEG Biofeedback as a Treatment for Substance Use Disorders: Review, Rating of Efficacy, and Recommendation for Further Research.” Applied Psychophysiology Biofeedback. 33:1–28.
Wanda K. Holloway, PsyD, LPC, CASAC, LCSW, BCB, EMDR Certified, graduated from Forest Institute of Professional Psychology with a Doctor of Psychology. Dr. Holloway is also a licensed professional counselor, certified advanced substance abuse counselor, licensed clinical social worker, certified forensics addictions examiner, and is Board certified in biofeedback and certified in EMDR. She is an outpatient counselor at Burrell Behavioral Health, a large community mental health facility located in the heart of the Ozarks in Springfield, Missouri. She specializes in addictive disorders, eating disorders and obesity, trauma and bio/neurofeedback.
In the 1960s heroin abusers were primarily young minority men in cities whose opioid abuse began with heroin, but this stereotypical image of a heroin addict has long been outdated. Today, heroin users are typically older, white, and living in nonurban areas, whose abuse started with prescription for opioid painkillers (Cicero et al. 2014). What is behind the dramatic shift in the demographic of heroin users over the past few decades?
Traditionally, opioids were used largely to treat pain caused by terminal diseases, or in the short term for acute pain, such as after surgery. Starting with Oxycontin in the mid-1990s, the Food and Drug Administration approved numerous opioid medicines and doctors began to accept them as treatments for all kinds of afflictions from back pain to cancer (Cicero et al. 2014). According to the Centers for Disease Control and Prevention (CDC), “Health care providers wrote 259 million prescriptions for painkillers in 2012, enough for every American adult to have a bottle of pills” (CDC 2014).
What is now considered to be overprescribing of this class of drugs contributed in large part to the current opioid addiction crisis (Cicero et al. 2014). “Given that prescription opioids are legal, prescribed by a physician, and thus considered trustworthy and predictable (e.g., the dose is clearly specified on a distinctive tablet or pill), many users viewed these drugs as safer to use than other illicit substances,” writes Theodore Cicero, a professor of neuropharmacology at Washington University, in The Journal of the American Medical Association. Imagine a suburban mother, an unlikely candidate for drug addiction, going to the doctor complaining of back pain, and months later finding herself addicted to opioids.
An addiction to opioid painkillers is powerfully consuming and poses a unique difficulty in that prescriptions are required to maintain it. Some people found their way to “pill mills”—doctors and clinics more than willing to prescribe continuous rounds of narcotics. Patients who become addicted also have taken to shopping around for new doctors to get these prescriptions, and some have resorted to other means to obtain their high, especially in areas where governments and healthcare providers have tried to curtail narcotic access.
In a study by Cicero et al. (2014), most subjects reported switching to heroin because prescription opioids were harder to obtain and much more expensive. The heroin fix is comparable since it essentially has the same active ingredients as prescription opioids. One survey respondent stated that “heroin is cheaper and stronger than prescription drugs and that the supply is typically pretty consistent. It is also much easier to use intravenously than pills and other prescriptions, which often take more complex methods to break down.” Prescription opioids primed people for heroin addiction, and have become the major contributor to heroin initiation (Cicero et al. 2014).
Prescription opioids directed heroin initiation in demographics that have historically had lower rates of heroin use. Today, heroin users tend to be 18–25 years old (CDC 2015). Heroin use has more than doubled among whites, and while men still lead, women aren’t far behind. The CDC found, in its recent study of the demographics of heroin abuse from 2002 to 2013, that heroin abuse in women doubled (CDC 2015). The rate of people abusing heroin doubled with a 35.7 percent increase from 2008 to 2010 alone, and this increase paralleled the increase in heroin-related overdose deaths reported since 2010 (CDC 2015). Some 8,200 Americans died of heroin overdoses in 2013 alone (CDC 2015).
The rise of heroin use in whites of rural and suburban America has not stopped short in reaching teenagers. Those aged 12 to 17 years comprise about one quarter of the total population of those with opioid addiction (CDC 2015). While the gateway drugs have been thought to be marijuana and alcohol, a recent New York University study found that three-fourths of high school heroin users are starting with prescription opioids (Palamar 2015). Gaining access to their parents’ medicine cabinets, teens are starting to experiment with opioid painkillers like Oxycontin, Percocet, and Vicodin (Palamar 2015). Teens may think they’re safe because they’re government approved, pharmaceutical grade drugs. They may take opioid pills a couple of times and go unharmed, but many don’t realize these pills can be physically addicting (Palamar 2015). Ultimately, a recreational habit becomes a dangerous, full-blown opioid addiction that can quickly transition to heroin addiction.
In California Watch’s documentary “Suburban Junkies” about teenage heroin abuse in Orange County, California, one teen explained how he gained access to opioid painkillers through his cancer-stricken grandfather’s home. He soon realized that he could obtain the same high through heroin much more cheaply: “I was doing six to seven [pills] a day. It was getting so expensive and I said, I could sell these for like fifty bucks and go buy a gram. One gram of heroin is the price of one pill, and a gram of heroin could last you three or four days. One pill could last you a couple hours,” he recounted (Suburban Junkies 2012).
It’s certainly time to put aside stereotypes about who’s shooting up heroin. The new whiter, more middle-class demographics of heroin abuse have helped change the conversation about drugs in America—galvanizing the drug reform movement’s pursuit of treatment-based approaches in lieu of sending drug users to jail and prison.
Cicero, Theodore J., et al. 2014. “The Changing Face of Heroin Use in the United States: A Retrospective Analysis of the Past 50 Years.” JAMA Psychiatry. 71(7): 821–826. Also available online at http://archpsyc.jamanetwork.com/article.aspx?articleid=1874575.. Accessed on January 5, 2016.
Palamar, Joseph J., et al. 2015. “Nonmedical Opioid Use and Heroin Use in a Nationally Representative Sample of US High School Seniors.” Drug and Alcohol Dependence 158(8): 132–138. Also available online at http://www.drugandalcoholdependence.com/article/S0376–8716(15)01747–0/fulltext Accessed on December 15th, 2015.
“Suburban Junkies.” 2012. California Watch. http://californiawatch.org/health-and-welfare/ rise-young-painkiller-abusers-officials-see-more-heroin-overdoses-17550. Accessed on December 15, 2015.
Ashley Rekem has a bachelor’s degree in biology from the University of California, Berkeley. Now living and studying in Maine, she writes the Chronic Conditions blog for the Bangor Daily News, focusing on healthcare and food as medicine.
Contemporary research has revealed an increase in social and economic problems for female heroin users. The current trend of substance abuse within the adolescent population has been steadily increasing since 1992 and continues today (Eaves 2004; Pugatch et al. 2001). A recent study found 68.75 percent of female participants were introduced to heroin through a male friend or boyfriend, and females are more likely to start using heroin if their romantic partner is currently using (Eaves 2004; Subramaniam and Stitzer 2009). The four sources for the increased use of heroin among adolescents have been identified as: its lower cost and increased availability, drug purity, and the misbelief of the consequences of heroin use (Lambie and Davis 2007; Pugatch et al. 2001). Individuals who snort heroin are more likely to move onto intravenous (henceforth, IV) use of this particular drug. The progression of use of highly addictive substances, such as heroin, by adolescents and emerging adults has been identified as: (1) drinking alcohol; (2) smoking cigarettes; (3) smoking marijuana; and (4) the use of hard narcotics, such as heroin or cocaine (Arnett 2013, 362–391; Subramaniam and Stitzer 2009). Finally, peer influence has contributed to the high rates of addiction within the adolescent population (Pugatch et al. 2001). The available literature surrounding heroin use neglects to acknowledge gender differences between heroin addicts, is outdated, and fails to address current drug trends within the adolescents and emerging adult population.
The gender differences between male and female heroin users range from first-use to intake methods. Female users are more likely to use the drug intravenously, engage in risk-taking behavior, and use the drug more often when compared to their male counterparts (Eaves 2004; Hölscher et al. 2009). The increase of risk-taking behaviors is often manifested as using needles after another injector, sharing needles with a sex partner, and engaging in sexual activities with more than one person when compared to men and similarly aged non-using females (Eaves 2004). Finally, the speed of use to addiction is faster for females: one study revealed that 46.5 percent of women compared to 22.4 percent of men self-reported their onset of addiction within the first three months of heroin use (Eaves 2004).
This progression of heroin use suggests a deeper problem for adolescent girls; although no direct connection has been made to addiction and childhood neglect, recent studies have found that female drug users report poor relationships with their fathers who were often uninvolved or absent (Eaves 2004). Eaves (2004) speculates that females who were introduced to heroin via a male figure are trying to compensate for the lack of a father figure during their developmental years. The impact of a user’s childhood on their propensity for substance abuse is a field that needs further exploration, although current studies reflect a causal effect between childhood trauma and/or neglect and future substance abuse (Eaves 2004; Hölscher et al. 2009). Finally, female heroin users are more likely to be diagnosed with psychiatric conditions when compared to male users (Hopfer et al. 2002; Lambie and Davis 2007; Subramaniam and Stitzer 2009). Numerous psychiatric disorders were found in both heroin and prescription opioid users: clinical depression, major depressive episodes and generalized anxiety disorder being the most prevalent; these individuals reported using their “drug of choice” to self-medicate and as a way of managing their emotional and psychological anguish (Hopfer et al. 2002; Lambie and Davis 2007; Subramaniam and Stitzer 2009).
The available body of literature discussing heroin use and adolescent females is considerably lacking. Current literature neglects to address gender differences within addicts and primarily emphasizes the deviant aspect of addiction such as incarceration. The potential causal relationship between childhood trauma and neglect experienced by a female heroin user needs further review. In order to address the epidemic of addiction, exploration of this phenomenon needs to be examined.
Arnett, J. J. 2013. Adolescence and Emerging Adulthood: A Cultural Approach, 5th ed. Upper Saddle River, NJ: Pearson Prentice Hall.
Eaves, C. 2004. “Heroin Use among Female Adolescents: The Role of Partner Influence in Path of Initiation and Route of Administration.” The American Journal of Drug and Alcohol Abuse. 30(1): 21–38.
Hölscher, F., et al. 2009. “Differences between Men and Women in the Course of Opiate Dependence: Is There a Telescoping Effect?” European Archives of Psychiatry and Clinical Neuroscience. 160: 235–241.
Hopfer, C., et al. 2002. “Adolescent Heroin Use: A Review of the Descriptive and Treatment Literature.” Journal of Substance Abuse Treatment. 23(3): 231–237.
Lambie, G. W., and K. M. Davis 2007. “Adolescent Heroin Abuse: Implications for the Consulting Professional School Counselor.” Journal of Professional Counseling: Practice, Theory, and Research. 35(1): 1–17.
Pugatch, D., et al. 2001. “Heroin Use in Adolescents and Young Adults Admitted for Drug Detoxification.” Journal of Substance Abuse. 13(3): 337–346.
Subramaniam, G. A., and M. A. Stitzer. 2009. “Clinical Characteristics of Treatment-Seeking Prescription Opioid vs Heroin-Using Adolescents with Opioid Use Disorder.” Drug and Alcohol Dependence. 101(1–2): 13–19.
Clariza Saint George currently works with survivors of sexual violence at Rape Victim Advocates in Chicago, Illinois. Her professional and academic work is focused on interpersonal violence and addiction studies. She is an A.M. candidate at the University of Chicago and earned her BA in psychology from Northeastern Illinois University.
The therapeutic relationship is often associated with enhancing motivation to change and involves listening, having empathy, and being collaborative and accepting among other facets (Norcross 2010). As a member of a peer group of other teenagers using drugs and alcohol, a desire to seek treatment may not often present due to the normalizing quality of friends who are also using substances. Consequently, when compared to adults, teenagers are less likely to seek treatment for substance use voluntarily (Melnick, De Leon, Hawke, Jainchill, and Kressel 1997). Moreover, per clinical observations in a community mental health program for adolescents seeking therapy for drug and alcohol treatment, the majority of teenagers presenting for therapy do so to appease some external source (e.g., parents, school administration, legal authorities). Therefore, given the external pressures associated with the circumstances surrounding therapy, it is understandable how a strong therapeutic relationship might benefit treatment outcome.
In addition, it seems that there is an assumption that entering a “substance abuse” program denotes that the primary focus of treatment must be abstinence from that substance (i.e., discontinuation of usage). The difficulty here is that substance use often co-occurs with other disorders, such as depression, anxiety, or other psychological difficulties (American Psychiatric Association 2013), as well as problems within the family of origin and peer group. Subsequently, substance use often becomes a form of self-medication and a way of coping with the aforementioned concurrent difficulties. For therapy to concentrate on eliminating substance use would be to overlook other present and underlying issues. Additionally, early therapeutic interventions targeted at drug-related behaviors may undermine the therapeutic relationship depending on the teenager’s goals in therapy.
The therapeutic relationship should institute a collaborative process, in which the teenager seeking treatment is directive and actively contributes and agrees upon goals set in therapy (Norcross 2010), for which the client should rank order. In providing the teenager with the freedom to guide the therapeutic process, the initial stages may address daily stressors and ongoing difficulties that the teenager is experiencing, not necessarily substance use. However, this process enhances the therapeutic relationship, thereby impacting the motivation to change. For example, a 17-year-old Caucasian female was referred to treatment by her parents, after having fallen asleep in class due to her recreational use of benzodiazepines. In addition to experimenting with benzodiazepines, the client was a regular cannabis user and presented with persistent depressive disorder. Per the client’s report, she did not fit the stereotypical image of an “addict” and did not see her usage as a problem. It became apparent that focusing on reducing and eliminating substance use would be unproductive for therapy and would hinder the development of the therapeutic relationship. Therefore, the therapeutic relationship became fundamental to the process of eliciting change. During her next individual session, the client was asked what she would like to accomplish in session that day. She expressed a desire to reduce the presence of depressive symptoms.
The next three months of therapy implemented interventions aimed at increasing behavioral activation, self-esteem, and emotion regulation. She was forthcoming and attended all scheduled sessions. Further, she successfully maintained long periods of abstinence, as evidenced by self-report and results of urinalysis. In this example, exhibiting empathy for the client’s other difficulties and allowing her to learn coping skills for more troubling mental health problems (i.e., depression) allowed her to explore the role that the substance played in coping with daily stressors and maintained other presenting problems.
Employing a motivational interviewing style while establishing the relationship is a commonly used approach that allows individuals to examine the evidence and consequences of their behaviors in a nonjudgmental way, and provides an opportunity for them to arrive at their own conclusions (e.g., Carroll, Libby, Sheehan, and Hyland 2001). This approach facilitates in generating more reasons to stop using and can be accomplished through techniques, such as decisional balance and scaling. Psychoeducation may also be advantageous by dispelling myths that teenagers possess regarding substances. For example, many teenagers report that they feel more social and outgoing while under the influence of alcohol; however, it is well established that alcohol is a depressant and that long-term use contributes to the presence or exacerbation of depressed mood.
Taken together, teenagers are in a unique situation where they are not always able to remove themselves from people, places, and things that may contribute to urges to use. This may have negative implications for their ability to manage certain stressors, such as family dysfunction or peer difficulties. Although the presence of external pressures may not negatively impact the therapeutic relationship, teenagers who report more reasons for wanting to stop using drugs exhibit better relationships with their therapist (Garner, Godley, and Funk 2008). Research demonstrates the importance of the therapeutic relationship on long-term gains, over and above specific interventions (Norcross 2010). Interventions specifically targeting substances may not be the only way to see improvements in drug-related behaviors. Therefore, the use of a collaborative relationship can facilitate cooperation and enhance motivation for therapy.
American Psychiatric Association. 2013. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, DSM-5.
Carroll, K. M., et al. 2001. “Motivational Interviewing to Enhance Treatment Initiation in Substance Abusers: An Effectiveness Study.” American Journal of Addiction. 10(4): 335–339.
Garner, B. R., S. H. Godley, and R. R. Funk. 2008. “Predictors of Early Therapeutic Alliance among Adolescents in Substance Abuse Treatment.” Journal of Psychoactive Drugs. 40(1): 55–65.
Melnick, G., et al. 1997. “Motivation and Readiness for Therapeutic Community Treatment among Adolescents and Adult Substance Abusers.” The American Journal of Drug and Alcohol Abuse. 23(4): 485–506.
Norcross, J.C. 2010. “The Therapeutic Relationship.” In Duncan, B.L., et al., eds. The Heart and Soul of Change: Delivering What Works in Therapy. Washington, D.C: APA.
Nicole Sciarrino is a third-year doctoral psychology trainee at Nova Southeastern University (NSU) in Fort Lauderdale, Florida, pursuing a specialization in the program’s Trauma Track. In the three years prior to beginning her studies at NSU, she became a certified alcohol and substance abuse counselor (CASAC) in New York State and worked in an outpatient substance use facility where she performed individual and group therapy treatment interventions with an urban population. More recently, Ms. Sciarrino has been working as the clinic coordinator for the Adolescent Drug Abuse Prevention and Treatment (ADAPT) Program and the research coordinator for the Trauma Resolution Integration Program (TRIP) at NSU.
The Merriam-Webster dictionary defines disease as “a condition that prevents the body or mind from working normally” and addiction as a “compulsive need for and use of a habit-forming substance” (Merriam-Webster Online Dictionary 2016). In contrast, depression is “a serious medical condition in which a person feels very sad, hopeless, and unimportant and often is unable to live in a normal way.” The dictionary makes it clear that depression is a disease. Concerning addiction, it’s a bit ambiguous, even though drug abuse prevents the “body or mind from working normally.” We need to stop talking about drug abuse as simply a bad habit, and instead start discussing how to treat and prevent addiction as an illness.
How do we change this perception? First, people need to know that addiction, similar to other mental illnesses, often has a partial genetic basis. Not everyone who experiments with drugs becomes an addict, and whether or not a person continues to abuse drugs is dependent on genetics approximately 50 percent of the time. DNA works in combination with environmental factors to alter our susceptibility to addiction. Twin studies are a great example of this: while identical twins who share genetic makeup are much more likely to become addicted to alcohol than non-identical (fraternal) twins, there is still no guarantee that they will become addicts (Enoch and Goldman 2001; Prescott and Kindler 1999). Genes for addiction make us susceptible, but do not pre-determine our fate.
A variety of genes, often in complex combinations, contribute to addiction vulnerability. Genes linked to alcoholism may be different from genes that influence smoking. Importantly, one of many reasons people abuse drugs is for self-medication purposes. A person who has depression may be more likely to abuse alcohol. Not surprisingly these two diseases are thought to share some molecular and genetic underpinnings (Kendler et al. 1995; Plemenitas et al. 2015; Wiers et al. 2015). Treating each of these illnesses individually or in combination (e.g., naltrexone for alcoholism and/or SSRIs for depression) may improve the patient’s health.
People sometimes argue that addiction is not a disease because some of the changes that drugs cause in the brain also occur in a healthy individual. Certain regions of the brain are involved in learning, and the brain uses specific proteins and molecules to help us form and retain memories. But healthy memories tend to be different from drug memories. Remembering the act of taking a drug, as well as the sensations associated with drug use, can stir up emotions and evoke an insatiable drive to obtain and consume drugs. A particular chemical messenger in the brain, dopamine, is partially responsible for this. Through unnaturally magnifying dopamine levels in the brain, both drugs and drug-related stimuli initiate craving. By communicating to us via dopamine, addictive substances “bully” people into pursuing drugs, encouraging individuals to obtain them even if it involves performing dangerous behaviors. The loss of control over our actions is a hallmark of the disease.
Drug memories are also long-lasting and difficult to forget; even if an addict is clean for years, memories of drug use may linger. This attribute of memory increases the probability someone will relapse into drug-taking, even after periods of abstinence. Indeed, permanent changes in brain structure, function, and connectivity are visible in individuals who have abused drugs (Seo et al. 2016). So, for a healthy person the sight of a spoon might suggest soup is for dinner, but for someone who previously used crack, seeing the spoon may motivate them to cook and smoke. The spoon does not cause a person to search compulsively for soup, but it has the potential to instigate a relentless hunt for crack. Because this uncontrollable behavior results from disorderly changes in the brain, we consider this addiction a disease.
The body and brain adapt over time to the effects of drugs in a variety of ways. Due to tolerance, some drug effects decrease with repeated administration. Regular alcohol drinkers are less impaired by a single shot of vodka than non-drinkers. In contrast, sensitization results in the increase of other drug effects with repeated dosing. Sensitization may enhance motivation to seek drugs via dopamine, exaggerate a drug’s cardiovascular impact, and promote body movement.
Unfortunately, the fickle nature of tolerance and sensitization make them particularly dangerous. For example, learning and memory can alter the degree to which a drug produces tolerance and sensitization. An individual might be tolerant to the effects of heroin at his or her home, but not at a local bar. The amount of heroin the individual needs to get high at home is, therefore, more than the quantity needed at the bar. This is a potentially deadly mistake. Taking the “usual” amount of drug at the bar can result in an overdose where our bodies “forget to breathe” (Gerevich, Bácskai, and Danics 2005). This phenomenon illustrates why drug abuse is not simply a result of “habit-learning” or brain mechanisms of learning gone awry.
By defining drug tolerance as one of several fundamental aspects of drug addiction, we can develop strategies to prevent untimely deaths from overdoses. One way to reverse an overdose of heroin or morphine is to inject the individual with an opioid antagonist. Medications such as Naloxone (Narcan) block the effects of heroin or morphine, potentially allowing the overdosing person to breathe again. Unfortunately, it is unpredictable whether an individual will overdose on a drug because tolerance levels can vary widely. We should, therefore, increase the number of people who are trained to deliver Naloxone. Equipping law enforcement personnel, nurses, and others with this medication will increase the likelihood that overdose patients will survive.
Several pathologies associated with addiction allow for its characterization as a disease. First, addiction runs in families and may have a strong genetic component. Second, addiction hijacks learning processes, uncontrollably motivating our behavior and predisposing us to relapse. Lastly, addiction causes long-lasting changes in the brain which lead to either tolerance or sensitization of specific drug effects. These adaptations are dangerous because they can have unforeseeable consequences, potentially resulting in overdose and death. Importantly though, by identifying at-risk individuals we can take measures to prevent the development of addictions. For those individuals who are addicted, we can both treat the illness and reduce the potential harm the disease causes.
Enoch, M. A., and D. Goldman. 2001. “The Genetics of Alcoholism and Alcohol Abuse.” Current Psychiatry Reports. 3: 144–151.
Gerevich, J., E. Bácskai, and Z. Danics. 2005. “A Case Report: Pavlovian Conditioning as a Risk Factor of Heroin ‘Overdose’ Death.” Harm Reduction Journal. 2: 11.
Kendler, K. S., et al. 1995. “The Structure of the Genetic and Environmental Risk Factors for Six Major Psychiatric Disorders in Women. Phobia, Generalized Anxiety Disorder, Panic Disorder, Bulimia, Major Depression, and Alcoholism.” Archives of General Psychiatry. 52: 374–383.
Merriam-Webster Online Dictionary. <http://www.merriam-webster.com/dictionary/>. Accessed on January 21, 2016.
Plemenitas, A., et al. 2015. “Alcohol Dependence and Genetic Variability in the Serotonin Pathway among Currently and Formerly Alcohol-Dependent Males.” Neuropsychobiology 72: 57–64.
Prescott, C. A., and K. S. Kendler. 1999. “Genetic and Environmental Contributions to Alcohol Abuse and Dependence in a Population-Based Sample of Male Twins.” American Journal of Psychiatry. 156: 34–40.
Seo, S., et al. 2015. “Predicting the Future Relapse of Alcohol-Dependent Patients from Structural and Functional Brain Images.” Addiction Biology. 20(6): 1042–1055.
Wiers, C. E., et al. 2015. “Effects of Depressive Symptoms and Peripheral DAT Methylation on Neural Reactivity to Alcohol Cues in Alcoholism.” Translational Psychiatry 5: e648.
Bryan F. Singer received his PhD in neurobiology from the University of Chicago and is currently a research fellow in biopsychology at the University of Michigan. His current research aims to understand how individual variation in dopamine neurotransmission contributes to the development of a variety of disorders, including drug addiction.
From 2011 to 2014, I had the great privilege of working at a residential substance abuse and mental health facility in Palm Beach County, Florida. My role there as behavioral health technician (BHT) was much more clinically oriented than other South Florida rehabs, which hired BHTs to simply drive vans and ensure the safety of clients: I facilitated groups, aided in therapeutic interventions, and worked intimately with our patient population. I primarily oversaw our adolescent program as lead tech and was able to help teens 13 to 18 years old from a variety of backgrounds, including two transgender adolescents: one (male-to-female (MTF) and one (female-to-male) FTM, who came to treatment for emotional issues and substance abuse. Both youths stayed under our care for over six months on an inpatient basis, and one continued to attend aftercare for over a year in an outpatient capacity. While our staff was extremely LGBT-friendly (the CEO and head psychiatrist is openly gay), having gender-variant teenage patients presented a unique set of obstacles, exposed our shortcomings as a clinical staff, and provided a rare learning experience to all of us.
One of the first issues I became aware of early on is that as adolescents, the patients I worked with rarely identified as “addicts.” Teenagers typically have adults running their lives and are too young to experience the often-devastating consequences of severe, long-term substance abuse compared to adults. Not surprisingly, our adolescent patients were almost invariably forced into treatment by their concerned parents, but did not necessarily meet diagnostic criteria for chemical dependency. Adolescents use substances for a variety of reasons, including “peer pressure, the desire to experiment with something new, to seek independence from parents, or for pleasure” (Jordan 2000). Hence, treating any adolescent—not just gender-variant youths—in a substance abuse setting is complicated because drug use may not be indicative of psychopathology, addiction, or even social deviance. With an estimated 42.5 percent of teens admitting use of illicit drugs and 16.4 percent reporting abuse, attendance in treatment was not a substantiation of addiction (Swendsen et al. 2012). As a treatment team, we focused on providing sufficient psychoeducation, improving coping strategies, and helping to enhance support networks, all in an effort to minimize the likelihood of addiction in adulthood. We were regularly met with resistance and resentment, particularly from our transgender patients, as they believed their parents had simply sent them away to avoid having to accept their gender nonconformity.
Since our adolescent program heavily emphasized 12-step Fellowship for addiction, AA/NA (Alcoholics Anonymous/Narcotics Anonymous) meetings presented another challenge particularly for our gender-variant teens. Aside from the fact that most of our patients felt they did not belong in an AA meeting, all 12-step–based programs involve sponsorship for members. About half of our teens hailed from areas outside South Florida and intended to return to their families, which meant that obtaining a sponsor in the area would be minimally useful due to their limited time in treatment. Transgender teens had a harder time, as they required a sponsor who would be understanding and accepting of gender variance. For this reason, I sought out AA meetings which were listed as LGBT-friendly; although the people were welcoming and encouraging, they were mostly sexual minorities rather than gender nonconforming. As Benson explained in 2013, “Sexual orientation and gender identity both rely on sex/gender categories” but differ “in that sexual orientation is determined by who a person is attracted to, while gender identity is based on a person’s belief about who they are.” Unfortunately, our trans adolescents quickly learned that they were as underrepresented among the recovery community as they were with the inpatient population.
Consequently, the most difficult aspect of treating transgender adolescents with substance abuse is the universal and ubiquitous social isolation they experience. Clinicians at my facility were not always able to provide competent care, often using incorrect pronouns when referring to a trans teen and lacking a general knowledge of gender minority issues. Furthermore, the DSM-5 (Diagnostic and Statistical Manual of the American Psychiatric Association) still lists “Gender Dysphoria” as a psychiatric disorder, which “pathologizes a minority community, and potentially interferes with their pleas for civil rights and acceptance” (Lev 2013). Our gender-variant adolescents would frequently experience frustration, and rightfully so, stemming from marginalization both intentional and nuanced. There were certainly times when I wondered, had I been “born in the wrong body” (as my teens had described it) and lived through the same painful experiences, would I not also have considered turning to drugs or other self-destructive behaviors at some point? Gender-variant youth are already at a higher risk for suicide and self-harm as a result of social rejection and victimization, so it is not too shocking that drugs and alcohol sometimes serve to help a transgender adolescent temporarily escape a culturally oppressive society (Liu and Mustanski 2012). With so much transphobia and gender-normative thinking, were our gender-variant teens on the road to drug addiction, or were drugs just a manifestation of the emotional turmoil plaguing them? The answer was as convoluted and indecipherable to me then as it is now.
The teenage years are universally regarded as a strenuous time for everyone, across all cultures and identities. Dealing with substance abuse as teen is even more problematic, but coupled with the hardships implicit in the transgender experience, treating gender nonconforming youth is exceptionally difficult. Despite the vast amount of information that has been gleaned in the past several years about the psychological nature of gender identity and about substance abuse, the most appropriate approaches and conceptualizations of addiction treatment for transgender patients will continue to evolve as more is learned and currently leave much to be desired. As challenging and complicated as it may be, it is absolutely quintessential for transgender youth to have an affirming, knowledgeable, and compassionate support network, especially in inpatient settings. Above all, it would be an injustice to the gender-variant, substance-abusing teen to have those entrusted to help them toward wellness and recovery fail to be ever mindful of the intersectionality inherent in their issues.
Benson, K. E. 2013. “Seeking Support: Transgender Client Experiences with Mental Health Services.” Journal of Feminist Family Therapy. 25(1): 17–40.
Jordan, Karen M. 2001. “Substance Abuse among Gay Lesbian, Bisexual, Transgender, and Questioning Adolescents.” School Psychology Review. 29(2): 201.
Lev, A. I. 2013. “Gender Dysphoria: Two Steps Forward, One Step Back.” Clinical Social Work. Journal. 41(3): 288–296.
Liu, R. T., and B. Mustanski. 2012. “Suicidal Ideation and Self-Harm in Lesbian, Gay, Bisexual, and Transgender Youth.” American Journal of Preventive Medicine. 42(3): 221–228.
Swendsen, J., et al. 2012. “Use and Abuse of Alcohol and Illicit Drugs in US Adolescents: Results of the National Comorbidity Survey–Adolescent Supplement.” Archives of General Psychiatry. 69(4): 390–398.
Michael Vallario is a second-year clinical psychology trainee in the PsyD program at Nova Southeastern University’s College of Psychology. He currently works at Fort Lauderdale Hospital as a recreation services specialist. Michael hopes to specialize in treating adolescents and the LGBT population.
First Lady Nancy Reagan, wife of President Ronald Reagan, discusses her policy to reduce drug use among teens, who should “Just Say No” to drugs and alcohol. Experts disagree as to the extent to which the program was successful in reducing youth substance abuse, if at all. (National Archives)